(Nov. 15, 2016) The dire shortage of beds for individuals in psychiatric crisis is the most obvious byproduct of a half-century of public policy designed to incentivize the closure of psychiatric hospitals. But it is not the only one. Closely related is the shrinkage of psychiatric “length of stay” or LOS - the duration of the patient’s hospital stay. In the latest original study from the Office of Research and Public Affairs, the Treatment Advocacy Center conducted a novel comparative analysis of state hospital data reporting LOS and readmission to the hospitals with 30 and 180 days.
Released, Relapsed, Rehospitalized found states that hospitalized severely ill psychiatric patients for shorter periods of time in 2015 had significantly higher hospital readmission rates within six months of discharge than states with longer median stays. The findings suggest that discharging patients “quicker but sicker” may have the unintended consequence of fueling revolving-door hospitalization, a pattern that disrupts mental health recovery and increases treatment costs.
“Quicker but Sicker?”
Reducing how long patients remain hospitalized is a common tactic for treating more patients without providing more beds. LOS reductions have been ongoing for decades: From 1980 to 2013, the average hospital stays for acute schizophrenia shrank from 42 days to seven days. At the same time, rehospitalization rates rose. The inevitable question the twin trends raise - do shorter lengths of stay result in higher rehospitalization rates? - has been studied sporadically since the early 1990s, without producing a clear answer. Different researchers using different methods with different patient populations arrive, probably unsurprisingly, at different conclusions.
In Released, Relapsed, Rehospitalized, we call on Congress to fund the necessary research to assess the role of shorter hospital stays on psychiatric readmission. We also call for federal analysis to determine the comprehensive cost of rapid rehospitalization, including emergency, criminal justice and homelessness services delivered between hospital discharge and readmission.
Why “More Research”?
The individual, social and economic costs of severe psychiatric diseases such as schizophrenia and bipolar disorder are staggering. Individuals diagnosed with these conditions live shorter lives with vastly greater likelihood of experiencing innumerable negative consequences. The direct and indirect costs of schizophrenia alone were $155 billion in 2013, or about $44,773 per individual with the disease.
Yet, unlike a host of other diseases, the prognosis and outcomes of serious mental illness are not improving, and some are worsening. Scratching the surface of a topic like rehospitalization rates immediately uncovers an information void that complicates addressing the problem. “More research” is a common recommendation in studies of mental health issues.
What are the components of psychiatric hospitalization that promote stabilization and recovery? What is the optimum hospital LOS to minimize risk of relapse and rehospitalization? Do sub-optimum stays reduce the chances of successful recovery? What community-based services, medications and other support lower the risk of relapse?
Without answers, solutions remain elusive.
Also Newly Reported
Since Released, Relapsed, Rehospitalized went to print, two new studies have been published in the psychiatric literature looking at the issue of rehospitalization and means of reducing it.
Joanna P. MacEwan and colleagues looked at the Medicaid records of more than 17,000 patients to assess whether patients who receive antipsychotic medications by injection rather than orally are less likely to return to the hospital within 60 days. They arrived at an unequivocal conclusion: Yes. Patients with either a sole or a comorbid diagnosis of schizophrenia who received long-acting injectable antipsychotics were significantly less likely to be readmitted to the hospital than those taking oral medications.
“Although the absolute differences may appear relatively small (approximately 5%), they can be of great value to patients and payers alike,” the authors concluded.
In the same November 2016 issue of Psychiatric Services, Catherine A. Fullerton and colleagues looked at how services after hospital discharge influence rehospitalization risk and emergency department visits. Their findings were less encouraging. Use of intermediate services following hospital discharge was not significant in reducing readmission to the hospital within 90 days.
Just as the Treatment Advocacy Center did, the authors concluded that identifying the “levers” that could reduce hospital readmissions and improve mental health outcomes is important. They called for additional research to “develop an understanding of the impact of the type and number of intermediate services on outcomes.
Doris A. Fuller
Chief of Research and Public Affairs
References:
- Fuller, D.A. et al. (November 2016). Released, relapsed, rehospitalized. Length of stay and readmission rates in state hospitals, a comparative state survey. Treatment Advocacy Center.
- MacEwan, J.P. et al. (November 2016). Hospital readmission rates among patients with schizophrenia treated with long-acting injectables or oral antipsychotics. Psychiatric Services.
- Fullerton, C.A. et al. (November 2016). Intermediate services after behavioral health hospitalization: Effect on rehospitalization and emergency department visits. Psychiatric Services.
Next Week: Medications and the Risk of Violent Reoffending after Incarceration
Research Weekly is a summary published as a public service of the Treatment Advocacy Center and does not necessarily reflect the findings or positions of the organization or its staff. Full access to research summarized may require a fee or paid subscription to the publications.
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